The Changing Of The Guard. A Primer About Assigned Claims In Michigan.

The Michigan No Fault Assigned Claims Program And The Changing Of The Guard.

by Bret Schnitzer

When is the changing of the guard a bad thing for Michigan Residents? Is the insurance industry now singling out the the elderly, disabled, lower income families, motorcyclists, children, pedestrians, and/or those who chose not to have an automobile in their lifestyle? The Michigan No-Fault Statute has remained relatively unchanged for No-Fault benefits since its inception in 1973. The State administered Assigned Claims fund has, however, suddenly transferred the administration of Assigned Claims to the insurance industry. One of the first orders of business by the insurance industry after this transfer was to change the Assigned Claims application in a significant and drastic manner. It can be argued that the ease and availability to get Michigan No-Fault Assigned Claims benefits has now also been significantly and drastically altered. This new application change will likely have a major, negative impact on No Fault benefits being provided. This includes the loss of No Fault benefits for medical treatment, wage loss, household services, attendant care, prescription and medical mileage.

Since the Michigan No-Fault Statute was enacted on October 1, 1973, the State Of Michigan has operated and controlled the Michigan Assigned Claims Facility (MACF) in order to provide Michigan No-Fault benefits for those who do not have Michigan No-Fault insurance and do not otherwise qualify under the Michigan No-Fault priority schedule as set forth in the Michigan No-Fault Statute. Recently, however, the Public operation of the Michigan Assigned Claims has been suddenly and inexplicably privatized by the Insurance industry. The Secretary of State managed the Assigned Claims program until December 17, 2012, when it transitioned to the Michigan Automobile Insurance Placement Facility also known as the (MAIPF). The insurance companies have now created a much more complex and extensive application that must be completed in order to receive Michigan No-Fault benefits under the Michigan Assigned Claims. Some of the other new additions to this application are two new strong warnings that anyone who is filling out the form is subject to the penalty of fraud for “knowingly filing or causing to be filed a false information concerning a fact or thing material to the claim”. The Fraud warning and statement also has to be acknowledged and signed by the applicant. The exact fraud language is set forth as follows:

“FRAUD WARNING
A person who presents or causes to be presented an oral or written statement, including computer‐generated information, as part of or in support of a claim to the Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility for payment or any other benefit knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under section 4503 of the insurance code that is subject to the penalties imposed under section 4511. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment or benefits under the Assigned Claims Plan.
I understand that by submitting the application for benefits, the owner of the involved, uninsured automobile will be financially responsible for reimbursement of all no fault benefits paid and costs associated with this claim pursuant to the Michigan No Fault Act.”

The warning also advises the health provider completing the form for their patient they may also be held liable for fraud for an “incorrect fact or thing material to the claim”. The application is quite long and complicated, and may lead the applicant to feel threatened that mistake, lack of information or omission may amount to fraud. If the applicant does not know an answer to a question and guess are they liable for fraud? If a “full and complete investigation” is not conducted by the medical provider are they liable for “fraud”, by signing the oath, as the application suggests? These concerns are certainly a reasonable interpretation. The exact language of the oath is a follows:

“I have reviewed the application in its entirety and attest that the information contained therein is true and accurate. If I am a medical provider and am submitting this application on behalf of the injured person, I attest that I have thoroughly investigated and verified all documented information. All information I have supplied is a representation of information obtained from the injured person or their representative”.

The application also indicates that failure to complete any portion of the questions is an “incomplete” application for benefits which will not be considered. The applicant is thus forced to provide answers to questions they may not be qualified to answer. This is particularly problematic in light of the fraud warnings seemingly making any error in providing information an automatic disallowance of the No-Fault benefits and a “fraud” by the applicant. The exact language is as follows:

“￼￼￼Please note, if any of the boxes below are not acknowledged, the application will be considered incomplete and will be returned to the injured person or their representative for further completion. The claim cannot be considered until all acknowledgements are checked”.

Should the applicant be concerned about filling out this application as an injured party, a medical provider or even an attorney? We think the answer is a resounding “yes”. Even the attorney who assists their client in filling out the form is warned in the application that the “representative” of the client, “must be accurate and compete as to any material fact or thing, after a complete investigation” or be subject to “fraud”. What exactly does this overly broad warning mean? “complete investigation”? “Verifying all documented information”? “Any material fact or thing”? Is the insurance company signaling that the applicant has to obtain every medical record for the injured parties entire life in order to complete this application? If the injured party had a sore back once 20 years ago and forgot about it, have they committed fraud by not disclosing it? Does the attorney need to hire private investigators to interview every possible person to verify the information? Is this long, broad and complex form merely a thinly veiled attempt to “chill” the claimants rights to hire counsel, seek medical attention or otherwise receive Michigan No-Fault benefits under the Assigned Claims Act? Our opinion is that it is!

It is imperative to note that other types of insurance applications do not contain language similar to this application. Even, other No-Fault Application for benefits do not contain these extensive questions, warnings and oath. If the Assigned Claims application is not filled out completely then the party simply does not get their No-Fault insurance benefits. The application contains over 50 questions and 25 subparts or 75 questions in total. With two warnings about “fraud” in the application, and an overly burdensome oath. It appears, that the application is designed to act as a deterrent to qualify for the Assigned Claims benefits.

The Assigned Claims is reserved for those who do not have automobile insurance and do not live with a relative resident that has automobile insurance and are involved in a motor vehicle accident with either an uninsured vehicle or a hit and run vehicle. This coverage is designed to protect people that cannot afford automobiles in their household. Those that need to use the Michigan Assigned Claims may often times be “lower income families” or even “the working poor”. The assigned claims, however, does not only affect lower income families. Assigned Claims also often affects motorcyclists, the elderly, children, disabled, pedestrians or those who simply chose not to have an automobile in their lifestyle. All of these Michigan citizens are now being subjected to this new application, which is quite unlike other applications for No-Fault benefits in this State. In fact, one well known insurance company involved in this new process does not require an application for No-Fault benefits to be filled out at all for their own insured, but they require it for the Assigned Claims application. How blatantly unfair is that!

Is discriminating against lower income families, financially challenged, the elderly, children, motorcyclists, disabled, pedestrians or non-automobile households by making them complete an unprecedented, overly burdensome, complex and intimidating application for Assigned Claims a fair and just new system? We think not! It should also be emphasized that this Assigned Claims Application is not for those uninsured motorists without insurance on the subject accident vehicle, since those folks are already wholly barred from receiving any No-Fault benefits, anyway. It is instead reserved for those innocent victims of motor vehicle accidents that do not have an automobile or a relative with automobile insurance in their household and are hurt in an uninsured motor vehicle accident, or a hit and run vehicle.

In fact, the application expressly states that the insurance company will go after the owner of the uninsured vehicle to recoup any and all of the No-Fault benefits paid by the Assigned Claims Fund. This warning also is intended to discourage injury victims from applying for No-Fault benefits who are concerned that they will be recouped against the owner of the uninsured vehicle.The exact language from the new application is as follows:

“I understand that by submitting the application for benefits, the owner of the involved, uninsured automobile will be financially responsible for reimbursement of all no fault benefits paid and costs associated with this claim pursuant to the Michigan No Fault Act”.

Why does the new application require the applicant to affirm this information? In all Assigned Claims cases the insurance company sends out investigators to take statements and to contact the uninsured vehicle owner and make it very clear to them that they will be sued for every dollar paid out in No-Fault benefits, whether the accident was their fault or not. The insurance company also routinely files the lawsuit Judgment with the Secretary of State and ensure that uninsured’s drivers license will be revoked, until the judgment is paid to them in full. This procedure is particularly effective when an uninsured driver knows the injured party and can act is a deterrent to those victims from getting proper medical treatment. This tactic is particularly harmful to children who are often not taken for proper medical care in these situations.

What Should You Do?

If you are faced with the new Assigned Claims application please call Schnitzerlaw at (313) 389-2234 or visit us on the web to learn more about us. You should not complete this application without proper and experienced legal representation. Please call us before filling out this application. Remember, there are short time limits on filing the application, so contact us immediately, so that we can evaluate whether we can handle your case and assist you. Call us for all your auto accident needs. You may also consider contacting your State Representative and complain in writing about these new changes in the Michigan No Fault Assigned Claims Application. Whose interests are being represented here anyway? It looks like just the insurance companies. Below, you can read the entire new Michigan Assigned Claims Application For No-Fault Benefits.

Complete Reproduction Of The New Assigned Claims Application

APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS
￼￼￼￼￼￼￼￼￼￼Michigan Assigned Claims Plan
c/o Michigan Automobile Insurance Placement Facility PO Box 532318
Livonia, MI 48153‐2318
Phone: 734‐464‐8111
Please note, “you” referenced throughout this application is defined as the injured person applying for benefits.
This application must be completed, signed and received no later than one (1) year from the date of accident. Incomplete or illegible applications will be returned without assignment to a servicing insurer. Please also submit a copy of the police report, EMS run form and/or any other documentation that describes the motor vehicle accident at issue.
Injured Person Information

￼￼￼￼￼￼￼￼1. Name of Injured Person: First Name Middle Name Last Name
￼￼￼￼2. Date of Birth:
￼￼￼￼￼￼￼￼3. List any and all names you have previously or currently go by
￼￼￼￼￼￼￼￼￼￼￼￼4. Social Security #:
￼￼￼￼￼￼5. Injured Person’s Current Address Street Apt # City State Zip Code
￼￼￼￼￼￼￼￼￼￼￼6. Injured Person’s Address at the Time of the Accident Street Apt # City State Zip Code
￼￼￼￼￼￼7. Home Phone #
￼￼￼￼8. Work Phone #
￼￼￼￼9. Cell Phone #
￼￼￼￼￼￼￼￼11. Marital Status:
Married Legally Separated Divorced Never Married
￼￼￼￼￼10. Email Address
￼￼￼￼￼￼12. Date of Accident
￼￼￼￼￼￼￼13. Injured Person’s Driver’s License #
￼￼￼￼￼￼￼￼14. Driver License State
￼￼￼￼￼15. At the Time of the accident, were you a Michigan resident? Yes No a. If no, list state: __________________________________
￼￼￼￼￼￼￼16. At the time of the accident, did you have any auto insurance? Yes No a. If yes, list Name of Automobile Insurance Company & Policy Number
___________________________________________________________
￼￼￼￼￼￼￼￼Accident Information
￼￼￼￼￼￼￼￼￼￼￼￼17. Accident Location Street City State Zip Code
￼￼￼￼￼￼￼￼￼￼18. Provide a full description of how the accident occurred. Note: If you require additional space, please attach a separate sheet with details as part of this application.
￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼19. Was a police report made? Yes No
a. If yes, list name of police department & police report number: _______________________________________________________________________________
￼￼￼￼￼￼￼￼￼￼￼￼20. What was your position? Driver Occupant Pedestrian Motorcyclist
a. If you answered “Occupant”, where were you seated in the vehicle? Passenger Front Seat Passenger Back Seat
b. If you answered “Occupant” or “Driver”, did you have permission to use the involved vehicle?
Driver Side Back Seat Middle Back Seat Other _____________________
Yes No
￼￼￼￼￼￼￼￼￼￼￼￼￼21. Was the vehicle a motorcycle? Yes No If you answered “Yes”please provide the following:
a. List the name of the owner of the motorcycle: _____________________________________________________________________
b. Was the motorcycle insured at the time of the accident? Yes No
c. List the name and policy number of the motorcycle’s insurance company: ______________________________________________________________
￼￼￼￼￼￼￼￼￼￼￼￼￼22. Were you contacted by a doctor’s office or other person about this claim? Doctor Other None a. If you answered “Doctor” , please provide:
Name of Doctor Address
Phone Number ___________________________________________________________________________________________________________________________
b. If you answered “Other” , please provide:
Name Address Phone Number
___________________________________________________________________________________________________________________________
￼￼￼￼￼￼￼￼￼￼ACF‐01 (01/2013)

Injury Information
APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS
￼￼￼￼￼23. Were you injured in the accident? Yes No a. If yes, describe your injuries:
￼￼￼24. Are or were you treated by a doctor(s) for injuries from this accident? Yes No a. If yes, please provide:
Doctor’s Name Address
Phone Number ___________________________________________________________________________________________________________________________ b. Name of person who referred you to this doctor: _____________________________________________________________________________________
Note: If you were treated by more than 1 doctor, attach a separate sheet with contact information as part of this application.
￼￼￼25. Were treated in a hospital? Yes No a. If yes, what type of treatment did you receive? In‐Patient Out‐Patient
b. If yes, please provide:
Hospital Name Address Phone Number _________________________________________________________________________________________________________________________________
Note: If you were treated at more than 1 hospital, attach a separate sheet with contact information as part of this application.
￼￼￼26. Please list any pre‐existing conditions that you had before this accident and how long you have been treating for those conditions. ___________________________________________________________________________________________________________________________
27. Had you sought treatment for any prior conditions before this accident? Yes No Not Applicable
a. If yes, please provide the name, address and phone number(s) of each doctor and pharmacy you had treated with prior to this accident: Doctors/Pharmacy Name Address Phone Number
___________________________________________________________________________________________________________________________
Note: If you sought treatment from more than 1 doctor/pharmacy, attach a separate sheet with contact information as part of this application.
￼￼￼28. Were you taking any medications prior to this accident? Yes No
a. If yes, Please list the names of all medications: ________________________________________________________________________________________
￼￼￼29. Do you have a primary care doctor? Yes No a. If yes, please provide: Doctors Name Address
Phone Number ___________________________________________________________________________________________________________________________
￼￼￼30. Have you received any medical bills? Yes No
￼￼31. Do you expect to receive medical bills? Yes No
￼￼32. Are you eligible for any benefits under social security? Yes No
￼￼Medical Insurance
Employment Information
￼￼￼￼33. Do you have any kind of health insurance? Yes No a. If yes, please provide: Name of Health Insurance Co. Address
Phone Number ___________________________________________________________________________________________________________________________
Policy or Plan Number: __________________________ Member Number: ________________________ Group Number: _________

￼￼￼34. Are you a Medicare Beneficiary? Yes No a. If yes, what is your Medicare HICN #: ___________________________________________________
￼￼￼￼￼￼35. Were you employed at the time of the accident? Yes No a. If yes, provide the following information:
￼￼Name Address and Phone Number of Your Employer
￼￼Occupation
￼￼Average Weekly Gross Income at the time of the Accident
￼￼List the Date of Your Employment : From To
￼￼￼￼￼$
￼￼￼￼￼￼￼￼Note: If you were employed by more than 1 employer, attach a separate sheet with contact information as part of this application.
￼￼￼36. Have you missed any work because of your injuries? Yes No a. If yes, what is the first date you missed work? 37. Do you have a note from a doctor ordering you to stay home from work? Yes No a. If yes, please provide: Doctors Name Address
_____________________
Phone Number ___________________________________________________________________________________________________________________________
￼￼38. Have you returned to work? Yes No
a. If yes, what date did you return to work? _____________________
￼￼39. If not yet returned, have you been given a return date? Yes No a. If yes, return to work date: _____________________
￼￼￼40. Were you on the job at the time of the accident? Yes No
a. If yes, are you eligible for any benefits under workers compensation? Yes No
￼￼￼41. How did you normally get to work prior to this accident?
￼￼￼42. Are you eligible for any benefits under any other wage or salary continuation plan? Yes No
￼￼ACF‐01 (01/2013)

Entitlement Information
APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS
￼￼￼43. Was there damage to the vehicle you were occupying or struck by? Yes No Unknown If yes, describethe damage to the vehicle: ___________________________________________________________________________________________________________________________
￼￼a. Was the vehicle towed? Yes No If yes, please provide: Name of Towing Company Address
Phone Number
___________________________________________________________________________________________________________________________ b. Was the vehicle repaired? Yes No If yes, please provide:
Name of Repair Company Address
Phone Number
___________________________________________________________________________________________________________________________ c. Do you know the current location of the involved vehicle? Yes No If yes, please provide:
Phone Number ___________________________________________________________________________________________________________________________
Note: If you were struck by more than 1 vehicle as a pedestrian, attach separate sheet with contact information as part of this application. d. Did you lease or have use of the involved motor vehcle at any time before the date of the accident? Yes No If yes:
e. What was the frequency at which you used the vehicle?
Daily Once a Week Two or More Times Per Week Less than Once Per Month Rarely
f. Did you have your own set of keys to the vehicle? Yes No g. Did you or have you ever had to ask permission to drive the vehicle? Yes No
h. Have you ever been denied permission to use the vehicle? Yes No i. Did you ever put gas in the vehicle? Yes No
Location of Vehicle Address
j. Did you ever do any maintenance on the vehicle? Yes No
k. List the Name of the Owner/Registrant of Vehicle involved in the accident: First Name Middle Name
Last Name ____________________________________________________________________
Owner/Registrant’s Address and Phone Number ___________________________________________________________________________________________________________________________
l. Vehicle Involved:
Year Make Model Vehicle Identification Number (VIN) Plate Number State the Vehicle is Registered In
___________________________________________________________________________________________________________________________
m. Was there automobile insurance in effect for this vehicle on the date of the accident? Yes No Name of Automobile Insurance Company : _________________________________________________
n. If not you, list the name of the driver of this vehicle: First Name Middle Name _____________________________________________________________________________________________
o. Did the driver have automobile insurance in effect on the date of the accident? Yes No If yes:
Name of Automobile Insurance Company : ______________________________________________ Policy Number: _______________________________
p. If different than the injured person, did the driver of the vehicle have a Driver’s License at the Time of the Accident? Yes No
If yes, please provide: Driver License #: ______________________________________________
q. Were there any other occupants in the vehicle? Yes No If yes: How many occupants were in the vehicle? _____________
Occupant’s Name Address
Driver License State: ______________________
Phone Number ___________________________________________________________________________________________________________________________
Occupant’s Name Address Phone Number ___________________________________________________________________________________________________________________________Did any of the occupants have automobile insurance in effect on the date of the accident? Yes No If yes:
Occupant’s Name Name of Automobile Insurance Company Policy Number
___________________________________________________________________________________________________________________________
Note: If more than 1 occupant had insurance, attach separate sheet with contact information as part of this application.
If yes:
Policy Number: ____________________________
Last Name
￼￼￼44. Were there witnesses to the accident? Yes No If yes, please provide:
Witness Name Address ___________________________________________________________________________________________________________________________
Witness Name Address Phone Number ___________________________________________________________________________________________________________________________Note: If more than 2 witnesses, attach separate sheet with contact information as part of this application.
Phone Number
￼￼￼45. List all persons and their relationship to you that lived with you at the time of the accident:
Name Relationship
__________________________________________________________________ ______________________________________________________
__________________________________________________________________ ______________________________________________________
__________________________________________________________________ ______________________________________________________
If more than 3, attach separate sheet with information as part of this application.
￼￼￼￼￼￼￼￼ACF‐01 (01/2013)
Page 3 of 5
APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS Entitlement Information (continued)
￼￼￼￼46. Describe all motor vehicles owned by you or any relative residing in your home (including your spouse) on the date of the accident: If none, check here: Owner/Relationship Year, Make & Model of Vehicle Vehicle Identification Number Plate Number Insurance Co & Policy Number
￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼￼Note: If more than 3, attach separate sheet with contact information as part of this application.
￼￼￼47. Have you ever filed a claim for Personal Injury Protection Benefits? Name of Insurance Company
_______________________________________________________
Yes No a. If yes, please provide: Claim Number
_______________________________________________
￼￼￼48. Are you filing this claim because there is a dispute between two or more insurance companies for your Personal Injury Protection coverage? Yes No a. If yes, please provide:
Name of Insurance Company Phone Number Claim Number
___________________________________________________________________________________________________________________________ Name of Insurance Company Phone Number Claim Number
___________________________________________________________________________________________________________________________
49. Please advise what steps have been taken to determine that there is no other auto insurance coverage? (attach additional sheet(s) to complete statement if needed)
___________________________________________________________________________________________________________________________
￼￼￼Please note, if any of the boxes below are not acknowledged, the application will be considered incomplete and will be returned to the injured person or their representative for further completion. The claim cannot be considered until all acknowledgements are checked.
I have reviewed the application in its entirety and attest that the information contained therein is true and accurate. If I am a medical provider and am submitting this application on behalf of the injured person, I attest that I have thoroughly investigated and verified all documented information. All information I have supplied is a representation of information obtained from the injured person or their representative.
I acknowledge I have read the following fraud warning:
FRAUD WARNING
A person who presents or causes to be presented an oral or written statement, including computer‐generated information, as part of or in support of a claim to the Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility for payment or any other benefit knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under section 4503 of the insurance code that is subject to the penalties imposed under section 4511. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment or benefits under the Assigned Claims Plan.
I understand that by submitting the application for benefits, the owner of the involved, uninsured automobile will be financially responsible for reimbursement of all no fault benefits paid and costs associated with this claim pursuant to the Michigan No Fault Act.
If I have provided an email address, I understand that all future correspondence and information regarding this claim may be exchanged via the email contact provided.
￼￼Signature of Injured Person or Representative
X
￼Printed Name of Injured Person or Representative
X
￼￼￼Date:
￼Signature of Preparer (if different than above)
X
￼Printed Name of Preparer (if different than above)
X
￼￼￼￼Date:
￼￼￼￼Who prepared this application? Injured Person Attorney Third Party Biller Parent Legal Guardian If other than Injured Party, please provide:
Address: ______________________________________________________________ City: ___________________________________ State: _ Zip Code: ________ Phone Number: ________________________
￼￼￼Email, Fax or Mail the signed application to:
Michigan Assigned Claims Plan
c/o Michigan Automobile Insurance Placement Facility PO Box 532318
Livonia, MI 48153‐2318
Phone: 734‐464‐8111 Fax: 734‐943‐6068 Email: info@michacp.org
￼￼￼￼￼￼ACF‐01 (01/2013)
Page 4 of 5
APPLICATION FOR PERSONAL INJURY PROTECTION BENEFITS AUTHORIZATION FOR RELEASE OF INFORMATION
FRAUD WARNING
A person who presents or causes to be presented an oral or written statement, including computer‐generated information, as part of or in support of a claim to the Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility for payment or any other benefit knowing that the statement contains false information concerning a fact or thing material to the claim commits a fraudulent insurance act under section 4503 of the Insurance Code that is subject to the penalties imposed under section 4511. A claim that contains or is supported by a fraudulent insurance act as described in this subsection is ineligible for payment or benefits under the Assigned Claims Plan.
I hereby request and authorize the disclosure of protected health information and other records about me as described below: The name or other specific identification of the person(s) or class of persons authorized to receive the information: The Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility and/or their Servicing Insurers.
I understand that the information disclosed may be subject to redisclosure by the person(s) or class of person(s) receiving it and no longer protected by the federal privacy regulations. For the purpose of risk management, claim adjustment or administration, The Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility and/or their Servicing Insurers will have complete and unrestricted rights to OBTAIN, DISCLOSE, RELEASE, or MAKE USE of personal or privileged information about me which may include financial and wage statements, all medical records, hospital records, reports, charts, notes, histories, laboratory records and reports, diagnostic test reports, doctor’s and nurse’s notes, correspondence, and all other material, including x‐ray films, MRI’s, CT’s and EMG/NCS and charges for all care, treatment and prognosis at any and all times for any condition whatsoever.
I understand this authorization could include information with respect to HIV infection, AIDS, mental health, substance abuse, and alcohol abuse. Those who may RELEASE this information, to the extent permitted by applicable law, include health care providers, government agencies, other insurance companies, insurance data base operators, third party administrators, or managed care companies, their agents, or contractors.
I understand this authorization shall be valid for three years from the date accompanying my signature. I may revoke this authorization by notifying the medical provider and The Michigan Assigned Claims Plan maintained by the Michigan Automobile Insurance Placement Facility and/or their Servicing Insurers in writing of my desire to revoke it. However, I understand that if I revoke this authorization, it will not have any effect on actions they took before they received my revocation.
I agree that a photographic copy of this authorization shall be as valid as the original.
_______________________________________
Signature of Injured Party or Legal Guardian (if applicable)
_______________________________________ Printed Name of Injured Party
___________________________________ Printed Name of Legal Guardian
_________________________ Date
_________________________ Social Security Number
ACF‐01 (01/2013)